This document summarizes guidelines from the Brain Trauma Foundation for the management of severe traumatic brain injury. It defines severe TBI and describes the publication of the 4th edition guidelines in 2016. It provides levels of evidence and recommendations for various treatment topics including decompressive craniectomy, hypothermia, hyperosmolar therapy, cerebrospinal fluid drainage, ventilation therapies, anesthetics/sedatives, steroids, nutrition, infection prophylaxis, deep vein thrombosis prophylaxis, seizure prophylaxis, and intracranial pressure monitoring.
Point of critical care Ultrasound play a pivotal role in management of critically ill patients admitted in ICU . Its usage in this regard is ever growing . Here we discus about pearls and pitfalls of POCUS in Intensive care medicine.
Point of critical care Ultrasound play a pivotal role in management of critically ill patients admitted in ICU . Its usage in this regard is ever growing . Here we discus about pearls and pitfalls of POCUS in Intensive care medicine.
Aggressive preemtive multimodal including epidural or nerve block not only produce optimal analgesia but also may prevent the occurrence of chronic pain after surgical
Paracetamol as a single analgesic is only for mild and moderate pain.
However it can be combined with many analgesics to provide strong effect.
So, it can be the basic regiment for Multimodal Analgesia.
CPSP is a new emerging disease but can be a silent epidemic.
Optimal perioperative management may reduce the incidence of CPSP.
Minimal invasive surgical techniques
Agressive perioperative multimodal analgesia, inluding epidural or nerve blocks.
Appropriate management of acute pain is therefore not only a humane obligation, but also may prevent of chronic pain!
SUMMARY:
- Neurophysiologic monitoring not universally adopted but in many centers has become routine monitor for some surgical procedures
- Ideal neurophysiologic monitoring in the neurosurgical procedure should be: non-invasive (v.s invasive), high sensitivity & specificity, cost effective, easy to use, simple instrumentation, and real time or continous monitoring.
Aggressive preemtive multimodal including epidural or nerve block not only produce optimal analgesia but also may prevent the occurrence of chronic pain after surgical
Paracetamol as a single analgesic is only for mild and moderate pain.
However it can be combined with many analgesics to provide strong effect.
So, it can be the basic regiment for Multimodal Analgesia.
CPSP is a new emerging disease but can be a silent epidemic.
Optimal perioperative management may reduce the incidence of CPSP.
Minimal invasive surgical techniques
Agressive perioperative multimodal analgesia, inluding epidural or nerve blocks.
Appropriate management of acute pain is therefore not only a humane obligation, but also may prevent of chronic pain!
SUMMARY:
- Neurophysiologic monitoring not universally adopted but in many centers has become routine monitor for some surgical procedures
- Ideal neurophysiologic monitoring in the neurosurgical procedure should be: non-invasive (v.s invasive), high sensitivity & specificity, cost effective, easy to use, simple instrumentation, and real time or continous monitoring.
Inhospital management of AIS slides'19.pptxAbushuMohammed
The main goals in the initial phase of acute stroke management are to ensure medical stability, to quickly reverse conditions that are contributing to the patient's problem, to determine if patients with acute ischemic stroke are candidates for reperfusion therapy, and to begin to uncover the pathophysiologic basis of the neurologic symptoms.
Raised ICP: What are our option?
- Pathophysiology intracranial hypertension.
- Use Brain Trauma Foundation Guideline (first-tier and second-tier therapy).
- On going research is the effect of TH to decrease ICP.
Defines intracranial pressure, cerebral perfusion pressure and mean arterial pressure. Depict formula for caculating ICP, CPP& MAP. Enumerate both pathological and non- pathological causes for increased ICP. Explain Monroe Kellie hypothesis, pathophysiology of increase Intracranial pressure medical, surgical and nursing management of Increased intracranial pressure.
The Importance of Community Nursing Care.pdfAD Healthcare
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R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
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Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
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As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
2. SEVERE TRAUMATIC BRAIN INJRURY
• Loss of consciousness greater than 6 hours
• GCS score 3-8
3. Brain trauma foundation- 4
• Published in September 2016
• Collaboration by American Association of
Neurological Surgeons (AANS) and the Congress
of Neurological Surgeons (CNS) Joint Guidelines
Committee (JGC)
• Funding Source 1) The U.S. Army 2) The
Brain Trauma Foundation, through a contract
awarded to Oregon Health & Science University.
4. 4th edition
• 189 publications used for evidence—5 Class 1,
46 Class 2, 136 Class 3 studies, and 2 meta-
analyses.
• 7 years between the 3rd and 4th Editions , 94
new studies were added
5. LEVEL OF EVIDENCE
• High—High confidence that the evidence reflects the true
effect. Further research is very unlikely to change the
confidence in the estimate of effect.
• Moderate—Moderate confidence that the evidence reflects
the true effect. Further research may change the confidence
in the estimate of effect and may change the estimate.
• Low—Low confidence that the evidence reflects the true
effect. Further research is likely to change the confidence in
the estimate of effect and is likely to change the estimate.
• Insufficient— Evidence is unavailable or does not permit a
conclusion
6. LEVEL OF RECOMENDATIONS
• Level I recommendations were based on a
high-quality body of evidence.
• Level II A recommendations were based on a
moderate-quality body of evidence.
• Level II B and III recommendations were based
on a low-quality body of evidence
8. Major Changes-
• Cerebral Fluid Drainage- New topic.
• Decompressive Craniectomy-New topic.
• Deep Vein Thrombosis- For risks that are
traumatic brain injury-specific, direct evidence
was not identified. Indirect evidence was
identified and included.
• Intracranial Pressure Technology- Technology
assessment is outside the scope of management
guidelines and no longer included.
9. • Hyperventilation- Renamed Ventilation Therapies.
• Brain Oxygen Monitoring-Renamed Advanced Cerebral
Monitoring.
• Infection Prophylaxis- Focus on Ventilator Associated
Pneumonia and External
• Ventricular Drain infections. Indirect evidence was
identified and used.
• Intracranial Pressure Monitoring, Cerebral Perfusion
Pressure Monitoring, Advanced
• Cerebral Monitoring- Divided into (a) benefits and risks of
monitoring (Monitoring) and (b)
• values to be targeted or avoided (Thresholds).
10. Decompressive Craniectomy
• Cerebral edema can result from a combination of
several pathological mechanisms associated with
primary and secondary injury patterns in
traumatic brain injury
• As pressure within the skull increases, brain
tissue displacement can lead to cerebral
herniation, resulting in disability or death
• Surgical removal of a portion of the skull, known
as decompressive craniectomy (DC), has been
performed for the purpose of relieving elevated
intracranial pressure with outcome improvement
in specific TBI patients
11. • There have been variations in surgical
techniques, timing, and patient populations in
most of the observational studies published in
the last 2 decades
12. RECOMMENDATIONS
Level I
• There was insufficient evidence to support a Level I
recommendation for this topic.
Level II A
• Bifrontal DC is not recommended to improve outcomes as
measured by the Glasgow Outcome Scale–Extended (GOS-E) score at
6 months post-injury in severe TBI patients with diffuse injury
(without mass lesions), and with ICP elevation to values >20 mm Hg
for more than 15 minutes within a 1-hour period that are refractory
to first-tier therapies. However, this procedure has been
demonstrated to reduce ICP and to minimize days in the intensive
care unit (ICU).
• A large frontotemporoparietal DC (not less than 12 x 15 cm or 15
cm diameter) is recommended over a small frontotemporoparietal
DC for reduced mortality and improved neurologic outcomes in
patients with severe TBI.
13. HYPOTHERMIA
• Hypothermia is well recognized to preserve
cells and tissue in the face of metabolic
challenge.
• Hypothermia can be administered either early
after injury and prior to intracranial pressure
elevation, in which case it is termed
“prophylactic,” or as a treatment for refractory
intracranial pressure elevation, typically referred
to as “therapeutic.”
14. RECOMMENDATIONS
• Level I and II A - There was insufficient
evidence to support a Level I or II A
recommendation for this topic.
• Level II B - Early (within 2.5 hours), short-term
(48 hours postinjury) prophylactic hypothermia
is not recommended to improve outcomes in
patients with diffuse injury.
15. Hyperosmolar therapy
• intravenous administration of hyperosmolar
agents has become routine in the management of
intracranial hypertension and herniation syndromes
• Mannitol and hypertonic saline are routinely
employed hyperosmolar agents
• Hypertonic saline administration may be
hazardous for a hyponatremic patient. Although
mannitol can be used as a resuscitation fluid, its
eventual diuretic effect is undesirable in
hypotensive patients
16. • Mannitol was previously thought to reduce
intracranial pressure through simple brain
dehydration, both mannitol and hypertonic
saline work to reduce intracranial pressure, at
least in part, through reducing blood viscosity,
leading to improved microcirculatory flow of
blood constituents and consequent
constriction of the pial arterioles, resulting in
decreased cerebral blood volume and
intracranial pressure
17. • Level I, II, and III –
• Although hyperosmolar therapy may lower
intracranial pressure, there was insufficient
evidence about effects on clinical outcomes to
support a specific recommendation, or to support
use of any specific hyperosmolar agent, for patients
with severe traumatic brain injury.
• Current Standards - Mannitol is effective for
control of raised intracranial pressure (ICP) at doses
of 0.25 g/kg to 1 g/kg body weight. Arterial
hypotension (systolic blood pressure <90 mm Hg)
should be avoided.
18. CEREBROSPINAL FLUID DRAINAGE
• Management of external ventricular drainage
(EVD) systems in patients with severe traumatic
brain injury (TBI) remains a controversial topic.
• Three types
1 continuously monitor ICP and only intermittently
drain for ICP elevations.
2.continuous drainage of CSF with intermittent ICP
measurements.
3. A third option is to place both an EVD for
continuous drainage and an intra parenchymal
fiber optic pressure monitor for continuous ICP
measurements.
19. RECOMMENDATION
Level I and II
• There was insufficient evidence to support a Level
I or II recommendation for this topic.
Level III –
• An EVD system zeroed at the midbrain with
continuous drainage of CSF may be considered to
lower ICP burden more effectively than
intermittent use.
• Use of CSF drainage to lower ICP in patients with
an initial Glasgow Coma Scale (GCS) <6 during the
first 12 hours after injury may be considered
20. Ventilation therapy
• Patients with severe traumatic brain injury (TBI)
require definitive airway protection because they are
at risk of pulmonary aspiration or compromised
respiratory drive and function. They may also require
transient hyperventilation to treat cerebral
herniation.
• Normal ventilation is currently the goal for severe
TBI patients in the absence of cerebral herniation and
normal partial pressure of carbon dioxide in arterial
blood (PaCO2) ranges from 35-45 mm Hg.
• PaCO2 is the measure of arterial levels of carbon
dioxide levels and heavily depends on metabolic rate.
21. RECOMMENDATIONS
Level I and II A
• There was insufficient evidence to support a
Level I or II A recommendation for this topic.
Level II B
• Prolonged prophylactic hyperventilation with
partial pressure of carbon dioxide in arterial
blood (PaCO2) of 25 mm Hg or less is not
recommended.
22. • Hyperventilation is recommended as a
temporizing measure for the reduction of
elevated intracranial pressure (ICP).
• Hyperventilation should be avoided during the
first 24 hours after injury when cerebral blood
flow (CBF) is often critically reduced.
• If hyperventilation is used, jugular venous
oxygen saturation (SjO2) or brain tissue O2
partial pressure (BtpO2) measurements are
recommended to monitor oxygen delivery
23. Anesthetics, Analgesics, and Sedatives
• Anesthetics, analgesics, and sedatives are important and
commonly-used therapies in acute traumatic brain injury (TBI)
for a variety of reasons, including prophylaxis or control of
intracranial hypertension and seizures.
• Barbiturates have a long history of being used to control
intracranial pressure (ICP), presumably by preventing
unnecessary movement, coughing, and straining against tubes as
well as suppression of metabolism and alteration of cerebral
vascular tone.
• Depressed cerebral metabolism and oxygen consumption is
said to be neuroprotective in some patients.
• Anesthetics and sedatives, such as barbiturates, may also
improve coupling of regional blood flow to metabolic demands
resulting in higher brain oxygenation with lower cerebral blood
flow, and decreased ICP from decreased cerebral blood volume.
24. RECOMMENDATIONS
Level I and II A –
• There was insufficient evidence to support a Level I or Level
IIA recommendation for this topic.
Level II B
• Administration of barbiturates to induce burst suppression
measured by EEG as prophylaxis against the development
of intracranial hypertension is not recommended.
• High-dose barbiturate administration is recommended to
control elevated ICP refractory to maximum standard
medical and surgical treatment. Hemodynamic stability is
essential before and during barbiturate therapy.
• Although propofol is recommended for the control of ICP, it
is not recommended for improvement in mortality or 6-
month outcomes. Caution is required as high-dose propofol
can produce significant morbidity
25. Steroids
• Steroids were introduced in the early 1960s as a
treatment for brain edema. Experimental
evidence accumulated that steroids were useful
in the restoration of altered vascular permeability
in brain edema, reduction of cerebrospinal fluid
production, attenuation of free radical
production.
• The Corticosteroid Randomization After
Significant Head Injury Trial (CRASH) trial was
designed to provide high quality evidence on the
impact of steroids on TBI patients
26. RECOMMENDATIONS
Level I –
The use of steroids is not recommended for
improving outcome or reducing ICP. In patients
with severe TBI, high-dose methylprednisolone
was associated with increased mortality and is
contraindicated.
27. Nutrition
Seminal work from the 1980s demonstrated that
severe TBI was associated with increased energy
expenditure early after injury.
RECOMMENDATIONS:
Level I - There was insufficient evidence to support
a Level I recommendation for this topic.
Level II A Feeding patients to attain basal caloric
replacement at least by the fifth day and, at most,
by the seventh day postinjury is recommended to
decrease mortality.
Level II B -Trans gastric jejunal feeding is
recommended to reduce the incidence of ventilator
associated pneumonia
28. Infection Prophylaxis
Potential route of infection in traumatic brain injury
• ventilator associated pneumonias (VAP)
• central line-associated bacteremia
• intracranial pressure (ICP) monitoring / External
ventricular drain
• Urinary tract infection.
• (?) whether prophylactic intravenous (IV)
antibiotics reduces infection rates or increases the
risk for emergence of drug-resistant organisms.
29. RECOMMENDATIONS
• Level I - There was insufficient evidence to support a
Level I recommendation for this topic.
• Level II A - Early tracheostomy is recommended to
reduce mechanical ventilation days However, there is no
evidence that early tracheostomy reduces mortality or
the rate of nosocomial pneumonia.
The use of povidone-iodine (PI) oral care is not
recommended to reduce ventilator associated
pneumonia and may cause an increased risk of acute
respiratory distress syndrome.
• Level III -Antimicrobial-impregnated catheters may be
considered to prevent catheter-related infections during
EVD
30. Deep Vein Thrombosis Prophylaxis
• Knudson et al. found that head injury with an Abbreviated Injury
Score of >3- an independent predictor of VTE in trauma patients.
• TBI has been associated with up to 54% incidence of deep venous
thrombosis without prophylactic treatment
• 25% incidence in patients with isolated TBI treated with sequential
compression devices.
• Ekeh found that deep vein thrombosis (DVT) occurred in one-third
of moderate and severe TBI patients with isolated head injuries.
• Age, subarachnoid hemorrhage, Injury Severity Score >15, and
extremity injury were predictors of DVT.
• Severe TBI patients can be at significant risk for VTE due to
hypercoagulability resulting from the primary brain injury,
prolonged periods of immobilization, and focal motor deficits. If
untreated, DVT can result in potentially debilitating or fatal
pulmonary embolism
31. RECOMMENDATIONS
Level I and II
• There was insufficient evidence to support a Level
I or II recommendation for treatment of deep
vein thrombosis (DVT) in severe TBI patients.
Level III
• Low molecular weight heparin (LMWH) or low-
dose un fractioned heparin may be used in
combination with mechanical prophylaxis.
However, there is an increased risk for expansion
of intracranial hemorrhage.
32. Seizure Prophylaxis
• Acute symptomatic seizures- may occur as a
result of severe traumatic brain injury (TBI).
• Early post traumatic seizure-when they occur
within 7 days of injury
• Late post traumatic seizure- when they occur
after 7 days following injury. Post-traumatic
epilepsy (PTE) is defined as recurrent seizures
more than 7 days .
• clinical PTS may be as high as 12%, while that
of subclinical seizures detected on
electroencephalography may be as high as
20% to 25%.
33. The risk factors for early PTS include:
• Glasgow Coma Scale (GCS) score of ≤10
• immediate seizures,
• post-traumatic amnesia lasting longer than 30 minutes.
• linear or depressed skull fracture.
• penetrating head injury.
• subdural, epidural, or intracerebral hematoma.
• cortical contusion.
• age ≤65 years.
• chronic alcoholism
34. RECOMMENDATIONS
Level I -
• There was insufficient evidence to support a Level I
recommendation for this topic.
Level II A –
• Prophylactic use of phenytoin or valproate is not
recommended for preventing late PTS.
• Phenytoin is recommended to decrease the incidence
of early PTS (within 7 days of injury), when the overall
benefit is felt to outweigh the complications associated
with such treatment. However, early PTS have not
been associated with worse outcomes. At the present
time there is insufficient evidence to recommend
levetiracetam over phenytoin regarding efficacy in
preventing early post-traumatic seizures and toxicity.
35. Intracranial Pressure Monitoring
• A mainstay of the care of the patients with the
most severe brain injuries has been the
monitoring of—and treatment of—intracranial
pressure (ICP).
• What is clear from the literature is that
intracranial hypertension is an important
secondary insult after severe TBI, and its
alleviation plays a pivotal role in providing good
patient care to achieve optimal outcomes.
36. RECOMMENDATIONS
Level I and II A
• There was insufficient evidence to support a
Level I or II A recommendation for this topic.
Level II B
• Management of severe TBI patients using
information from ICP monitoring is
recommended to reduce in-hospital and 2-week
post-injury mortality.
37. • Intracranial pressure (ICP) should be monitored in
all salvageable patients with a severe traumatic
brain injury (TBI) (GCS 3-8 after resuscitation) and
an abnormal computed tomography (CT) scan.
An abnormal CT scan of the head is one that
reveals hematomas, contusions, swelling,
herniation, or compressed basal cisterns.
• ICP monitoring is indicated in patients with
severe TBI with a normal CT scan if two or more
of the following features are noted at admission:
age over 40 years, unilateral or bilateral motor
posturing, or systolic blood pressure (BP) <90 mm
Hg
38. Cerebral Perfusion Pressure Monitoring
Cerebral perfusion pressure (CPP) -the pressure gradient
across the cerebral vascular bed, between blood inflow
and outflow. Inflow pressure is taken as mean arterial
pressure (MAP), which by convention is calibrated to the
level of the right atrium of the heart.
• In normal physiology the outflow or downstream
pressure is the jugular venous pressure (JVP), which is
also calibrated to the level of the right atrium.
• Traumatic brain injury (TBI) is a special pathological
state in which pressure surrounding cerebral vessels—
intracranial pressure (ICP)— is elevated and higher than
the JVP. In this circumstance CPP will be proportional to
the gradient between MAP and mean ICP, and changes in
CPP can occur with alterations in either MAP or ICP.
39. RECOMMENDATIONS
Level I -
There was insufficient evidence to support a
Level I recommendation for this topic.
Level II B –
Management of severe TBI patients using
guidelines-based recommendations for CPP
monitoring is recommended to decrease 2-week
mortality.
40. Advanced Cerebral Monitoring
• transcranial Doppler (TCD)/duplex sonography,
• differences between arterial and arterio-jugular
venous oxygen (AVDO2), and measurements of
local tissue oxygen.
• Arterio-jugular AVDO2 globally measures cerebral
oxygen extraction.
Additional monitoring methods-
• microdialysis to measure brain metabolism
(glucose, lactate, pyruvate, and glutamate)
electrocorticography to determine cortical
spreading depression
41. RECOMMENDATIONS
Level I and II
• There was insufficient evidence to support a Level
I or II recommendation for this topic.
(Although patients with desaturations identified
with advanced cerebral monitoring have poorer
outcomes, Level II evidence showed no
improvement in outcomes for monitored patients.)
Level III –
• Jugular bulb monitoring of arteriovenous oxygen
content difference (AVDO2), as a source of
information for management decisions, may be
considered to reduce mortality and improve
outcomes at 3 and 6 months post-injury.
42. Blood Pressure Thresholds
• The level of systolic blood pressure (SBP) has long
been felt to play a critical role in the secondary
injury cascade after severe traumatic brain injury
(TBI).
• If autoregulation remains intact, a drop in SBP
triggers an autoregulatory vasodilation in an
attempt to maintain adequate brain perfusion.
This results in increased cerebral blood volume,
which in turn elevates intracranial pressure. If
autoregulation is not intact, there is dependency
on SBP to prevent cerebral ischemia, which has
been ascribed to be the single most important
secondary insult
43. RECOMMENDATIONS
Level I and II
• There was insufficient evidence to support a
Level I or II recommendation for this topic.
Level III
• Maintaining SBP at ≥100 mm Hg for patients
50 to 69 years old or at ≥110 mm Hg or above
for patients 15 to 49 or over 70 years old may
be considered to decrease mortality and
improve outcome
44. Intracranial Pressure Thresholds
• Intracranial pressure (ICP) is the pressure
inside the cranial vault and is affected by
intracranial contents, primarily brain, blood,
and cerebrospinal fluid. The intracranial
volume is constant. Since the intracranial vault
is a fixed space, ICP increases with an increase
in brain volume and cerebral blood volume,
increased cerebrospinal fluid production, and
or decreased cerebrospinal fluid clearance.
• These compensatory measures allow for ICP
to be maintained within the normal range of
0-10 mm Hg.
45. RECOMMENDATIONS
Level I and II A
• There was insufficient evidence to support a Level
I or II A recommendation for this topic.
Level II B
• Treating ICP above 22 mm Hg is recommended
because values above this level are associated
with increased mortality.
Level III
• A combination of ICP values and clinical and brain
CT findings may be used to make management
decisions
46. Cerebral Perfusion Pressure Thresholds
• Cerebral perfusion pressure (CPP)- MAP- ICP
• CPP-a surrogate measure for the delivery of
nutrients to the brain. Moreover, it is believed
that CPP is the blood pressure metric to which
brain auto regulatory mechanisms respond.
47. RECOMMENDATIONS
Level I and II A –
• There was insufficient evidence to support a Level I or II A
recommendation for this topic.
Level II B
• The recommended target cerebral perfusion pressure (CPP)
value for survival and favorable outcomes is between 60
and 70 mm Hg. Whether 60 or 70 mm Hg is the minimum
optimal CPP threshold is unclear and may depend upon the
patient’s auto regulatory status.
Level III
• Avoiding aggressive attempts to maintain CPP above 70 mm
Hg with fluids and pressors may be considered because of
the risk of adult respiratory failure
48. Advanced cerebral monitoring threshold
• The goal of the medical management of severe traumatic
brain injury (TBI) is to ensure that nutrient delivery to the
brain is optimized through the period of abnormal
physiology and brain swelling that follows the injury
• Historical means of examining brain health, such as the
Kety-Schmidt method, which remains a gold standard assay
for cerebral blood flow and metabolism, as well as xenon-
CT, which informs the former
• Both provide information about large brain regions, as does
jugular venous O2 monitoring (SjO2)
• Microdialysis techniques allow measurement of
metabolites in the brain’s extracellular fluid
49. RECOMMENDATIONS
Level I and II
• There was insufficient evidence to support
Level I or II
Level III
• Jugular venous saturation of <50% may be a
threshold to avoid in order to reduce mortality
and improve outcomes. recommendation for
this topic.